Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Tracheostomy Care Supplies
Policy #:MA05.034

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


A tracheostomy care or cleaning starter kit for a new tracheostomy (A4625) is considered medically necessary and, therefore, covered following an open surgical tracheostomy. Beginning two weeks post-operatively, a tracheostomy care or cleaning starter kit for a new tracheostomy (A4625) is no longer medically necessary and, therefore, not covered because a tracheostomy care kit for an established tracheostomy (A4629) would be appropriate.

A tracheostomy speaking valve is considered medically necessary and, therefore, covered as an add on to the trachea tube.

The table below lists the maximum number of items/units of service that are usually medically necessary. The actual quantity needed for a particular individual may be more or less than the amount listed depending on clinical factors that affect the frequency of supply changes. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the individual’s medical record. If adequate documentation is not provided when requested, the excess quantities will be considered not medically necessary and, therefore, not covered.

Code
Number per Month (unless noted)
A4364
4
A4402
4
A4450
40
A4452
40
A4456
50
A4481
62
A4623
62
A4625
31
A4626
2
A4629
31
A5120
150
A7501
1
A7502
1
A7503
1 per 6 months
A7504
62
A7505
2 per 3 months
A7506
62
A7507
62
A7508
62
A7509
62
A7520
1 per 3 months
A7521
1 per 3 months
A7522
1 per 12 months
A7524
1 per 3 months
A7526
31
A7527
2 per 3 months

A tracheostomy shower protector (A7523) is not covered by the Company because it is an item not covered by Medicare because it is a convenience item. Therefore, it is not eligible for reimbursement consideration.

A tracheostomy/laryngectomy tube plug/stop (A7527) is used as an alternative to a tracheostomy/laryngectomy tube (A7520, A7521, A7522). For an individual receiving a tracheostomy/laryngectomy tube plug/stop (A7527), a tracheostomy tube (A7520, A7521 and A7522) is considered not medically necessary and, therefore, not covered.

Supplies for care of a tracheostomy site are considered medically necessary and, therefore, covered for an individual following an open surgical tracheostomy that has been open or is expected to remain open for at least three months. The quantities of supplies included in a tracheostomy care kit are to provide all necessary quantities for the care of the tracheostomy site, and there must not be any additional quantity billed of these codes for this purpose. Additional supplies may be billed, as appropriate and necessary, only for care other than for a tracheostomy site, such as for speaking valves.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same
time.

Column I
Column II
A4625
A4626
A4629
A4626

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, tracheostomy care supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

A tracheostomy care or cleaning starter kit (A4625) contains the following:

Item
Number Included
Plastic tray
1
Basin
1
Sterile gloves
1 pair
Tube brush
1
Pipe cleaners
3
Pre-cut tracheostomy dressing
1
Gauze
1 roll
4x4 sponges
4
Cotton tip applicators
2
Twill tape
30 inches

A tracheostomy care kit for an established tracheostomy (A4629) contains the following:

Item
Number Included
Tube brush
1
Pipe cleaners
2
Cotton tip applicators
2
Twill tape
30 inches
4x4 sponges
2


Description

A tracheostomy is a surgically made opening that goes through the front of an individual's neck and into the trachea. It provides an air passage to assist with breathing when the usual route for breathing is obstructed or impaired.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 50.4: Tracheostomy speaking valve. [CMS Web site]. 09/09/88. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=247&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&. Accessed September 1, 2017.

Noridian Healthcare Solutions LLC. Local Coverage Determination (LCD).L33832: Tracheostomy Care Supplies. Effective Date 10/01/2015. Revision Effective Date 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Tracheostomy+Care+Supplies+LCD+and+PA/69c6a6ea-3549-44dc-b25d-1a4a9e8254b7. Accessed September 1, 2017.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

J95.00 Unspecified tracheostomy complication

J95.01 Hemorrhage from tracheostomy stoma

J95.02 Infection of tracheostomy stoma

J95.03 Malfunction of tracheostomy stoma

J95.04 Tracheo-esophageal fistula following tracheostomy

J95.09 Other tracheostomy complication

Z43.0 Encounter for attention to tracheostomy

Z93.0 Tracheostomy status



HCPCS Level II Code Number(s)



A4364 Adhesive, liquid or equal, any type, per oz

A4402 Lubricant, per oz

A4450 Tape, nonwaterproof, per 18 sq in

A4452 Tape, waterproof, per 18 sq in

A4456 Adhesive remover, wipes, any type, each

A4481 Tracheostoma filter, any type, any size, each

A4623 Tracheostomy, inner cannula

A4625 Tracheostomy care kit for new tracheostomy

A4626 Tracheostomy cleaning brush, each

A4629 Tracheostomy care kit for established tracheostomy

A5120 Skin barrier, wipes or swabs, each

A7501 Tracheostoma valve, including diaphragm, each

A7502 Replacement diaphragm/faceplate for tracheostoma valve, each

A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each

A7504 Filter for use in a tracheostoma heat and moisture exchange system, each

A7505 Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each

A7506 Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each

A7507 Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each

A7508 Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

A7509 Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each

A7520 Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each

A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

A7522 Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

A7524 Tracheostoma stent/stud/button, each

A7525 Tracheostomy mask, each

A7526 Tracheostomy tube collar/holder, each

A7527 Tracheostomy/laryngectomy tube plug/stop, each

L8501 Tracheostomy speaking valve

S8189 Tracheostomy supply, not otherwise classified

NOT COVERED

A7523 Tracheostomy shower protector, each


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA05.034
06/19/2019This policy has been reissued in accordance with the Company's annual review process.
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
10/11/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Tracheostomy Care Supplies.
05/25/2016This policy has been reviewed and reissued to communicate the Company's continuing coverage for tracheostomy supplies.
06/24/2015This policy has been reviewed and reissued to communicate the Company's continuing coverage for tracheostomy supplies.
01/01/2015This is a new policy.





Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 06/19/2019